Fast Track into OB Labor and Delivery

Lightening

Five Ps of Labor Passage Passenger Psyche Powers Pain

Passage: the bony pelvis and soft tissue False pelvis (upper flaring part) True pelvis (lower part) Inlet Middle Outlet Shaped like a wide curved funnel Soft Tissue Impacted by previous births Impacted by scaring

More on the true and false pelvis See text page 25 Divided by false line: linea terminalis Extends from sacroiliac joint to anterior iliopubic prominence The upper false pelvis support the enlarging uterus and guides fetus into true pelvis The TRUE pelvis however dictated the bony limits of the birth canal

Anatomical picture of pelvic inlet

Passage dimensions

Anatomical features of the pelvic outlet Page 25-26 Transverse diameter between the inner surfaces of the ischial tuberosities (spines) (bi ischial diameter) Anterior posterior measurement of outlet is between lower border of symphysis pubis and tip of sacrum.

Passenger Page 122 Fetal skull page 123 Lie: orientation to Mom’s spine Attitude: normally flexed Presentation: part entering pelvis Position: how a reference point on the fetal presenting part oriented within the mother’s pelvis

The Passenger

Passenger

Molding

Transverse Lie

Fetal Lie

Fetal Lie Longitudinal Fetal Presentation: Vertex

Attitude: Flexion/Extension

Fetal Attitude: a well flexed head

Attitude; Brow

Presentation: Breech

Presentation

Fetal Positions

Position: Posterior

Fetal Positions

Using Fetal Heart Tones to Determine Position

Psyche Woman’s mental state Emotional; not described as surgical procedure Mental State greatly impacts mothers ability to cope and tolerate discomfort Perception of pain Anxiety

Powers of Labor Involuntary forces of labor Contractions Mother’s pushing efforts

Contraction Cycle

Effects of contractions on the cervix Effacement Thins the cervix Before labor approximately 2 cm long Thinning of cervix is expressed in % 100% thin slick membrane at edge of fetal head Dilation Opening of the cervix Described in cm of opening Full dilation at 10 cms

Effacement and Dilation

Effects of Contractions on Cervix

Effacement

Dilation

Mechanisms of Labor Descent Flexion Rotation Extension Restitution External Rotation

Engagement: Stations

Mechanisms of labor with effacement and dilation

Read to learn activity Signs of impending labor (page 131) Signs of True Labor (136) Signs of False Labor (135-136) Read those sections and then we will do a quiz together. RELAX!

Contractions; Page 120-21 Frequency Duration Interval Increment/Peak/decrement Intensity: Mild, moderate, strong

Contraction Monitoring The basics Frequency From the beginning of one contraction to the beginning of the next contraction Duration From the beginning of one contraction to the end of that contraction Interval The space between two contractions; from the end of one contraction to the beginning of the next one

Rule of contractions Based on infant getting adequate oxygenation The frequency must not be less than two minutes The duration must not be more than 90 seconds The interval must not be less than 60 seconds

Fetal Heart monitoring Intermittent Allows freedom of movement Does not offer a continuous record Obtain a baseline rate Rule: any FHR outside the normal limits or slowing that persists after the contraction ends is promptly reported to the health care provider See box 6-2 page 133

Continuous Fetal Heart Monitoring Offers a written record Allows collection of more data May however run a strip on admission and then re run a strip at regular intervals during the labor Referred to in terms of reassuring and non reassuring patterns. Box 6-3 page 135

Fetal and Contraction Monitoring The Basics Top of strip is the fetal heart monitoring Bottom of strip is the contraction pattern Each small square is 10 seconds Between each bold line is 60 seconds

Reassuring fetal heart/contraction pattern 110-160 bpm Variability Accelerations Early decelerations Contraction frequency greater than every 2 minutes, duration less than 90 seconds; relaxation interval of at least 60 seconds.

Non reassuring patterns Fetal tachycardia Fetal bradycardia Variable decelerations Late decelerations Absences or decreased variability

Decelerations Early Late Variable Due to fetal head compression during contractions and are expected Late Due to utero-placental insufficiency and are non reassuring Variable Due to cord compression and are non reassuring.

Early decelerations Reassuring pattern of deceleration during the early contraction due to fetal head compression Always return to baseline before the end of the contraction They often mirror a contraction

Picture of an early deceleration

Late deceleration NON reassuring Due to lack of oxygen to the baby Uteroplacental insufficiency Do NOT return to baseline FHR after the contraction ends

Picture of late deceleration

Variable Deceleration Due to cord compression V, W, or U shaped Do not exhibit a consistent pattern in relation to the contractions

Picture of variable deceleration

Nursing responses to non reassuring patterns Reposition mom, especially helpful in the variable decelerations Oxygen 100% per tight face mask IV fluids to expand blood volume and to dilute Pitocin (if given) Stopping Pitocin Giving tocolytic drugs to decrease uterine contractions

More FH patterns to look at

Stages of Labor First Second Third Fourth Onset of labor until cervical effacement and dilation is complete (10 cm) Second From the completion of effacement and dilation until the baby is born Third Expulsion of placenta Fourth Recovery phase

First stage divisions Latent Active Transition 4-6 hours 1-4 cm Mild to moderate intensity Active 2-6 hours 4-7 cm Moderate to firm intensity Transition .5-2 hours 7-10 cm Firm intensity

Descent

Mechanism of Labor, Continued

Mechanism of labor; continued

Delivery of shoulders

Second Stage Second stage is also divided into three stages in other texts Uncontrollable urge to push if no epidural Exhaustion after each contraction Unable to follow directions “BABY IS COMING!!!”

Baby is HERE!

Third stage Expulsion of placenta Elation and relief Shivers and tremors Signs of placental seperation Lengthening of cord Uterus rises and becomes firm Fresh blood expelled from vagina

Recovery Period Number one priority for the mother’s care is prevention of hemorrhage Infant care focuses on airway, breathing and circulation maintaining body temperature maintaining blood glucose Critical period of bonding and breast feeding.

Immediate care of Mother Assessment and care bullets; Page 148 Observing for hemorrhage Maintaining a firm fundus Preventing bladder distention Promoting comfort Ice pack Warm blanket Assisting with breast feeding Assessment of lower extremities

Immediate Care of the Infant First hour infant is in “quiet alert” phase and this is critical time form bonding and breast feeding. Unless the infant is in a medical emergency most of care can be done right at mother’s breast Now let’s see what will happen when you observe a birth!!!!

Immediate Care of Infant APGAR score Keep warm: dry and place on mothers chest: skin to skin with blanket over and cap on Assure that the nose is clean, bulb suction nose as well as mouth. Usually done at perineum Clamp the cord. Vigilant observation of infants cardiorespiratory status

Later Needs of the Infant Detailed examination Bath Erythromycin eye ointment Aquamephyton (vitamin K injection)] Hepatitis B vaccination

APGAR Score; Page 143

APGAR Score Let’s take some time to score to do the critical thinking exercise on APGAR scoring found in your workbook

NCLEX Prep question A client at 38 weeks gestation tells the nurse that it feels like her baby is sitting on her bladder causing her to urinate more frequently. However, the client states it has made it easier for her to breathe. The nurse recognizes that this is a sign of: Lightening Quickening Contractions Flexion

NCLEX Prep Question A client reports that her contractions started about 2 hr ago, did not go away when she had two glass of water and rested, and became stronger since she started walking. She thinks the contractions occur every 10 minutes and last about half a minute. She hasn’t had any fluid leak from her vagina, however, she did think she saw some blood when she wiped after voiding. The nurse should recognize that the client is experiencing: Braxton Hick contractions Rupture of membranes Fetal descent True Contractions

NCLEX Prep Question A nurse is monitoring the FHR and contractions of a client in labor. The FHR is in the 140s. Contractions are every 5 min and 45-50 sec in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced and the fetus is at the -2 station. One hour later the dilation is still 2 cm, but now the effacement is 80% Which of the following stages and phases of labor is this client experiencing? The first stage, latent phase The first stage, active phase The first stage, transition phase The second stage of labor

NCLEX Prep Question A nurse is admitting a client to the birthing unit. The client suddenly states, A”I think I urinated on myself. It’s all wet down there, I’m so embarrassed.” Which of the following actions should the nurse take at this time? Test the fluid with Nitrazine paper, it will confirm urine by turning blue Test the fluid with Nitrazine paper, which will confirm urine by turning pink. Test the fluid with Nitrazine paper, which will confirm amniotic fluid by turning it blue Test the fluid with Nitrazine paper, which will confirm amniotic fluid by turning it yellow.

NCLEX Prep Question A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. The nurse’s first action should be to: Test to see if the fluid is amnionic fluid Monitor fetal heart rate for distress Dry the client and make her comfortable Monitor the client’s maternal contractions

NCLEX prep question While conducting an admission history for a client at 39 weeks gestation, the client tells the nurse that she has been leaking water from her vagina for 2 days. The nurse knows that this client is at risk for: Cord prolapse Infection Malpresentation. hydramnios

NCLEX Prep Question A client in active labor becomes nauseous with emesis, is very irritable, and feels she needs to have a bowel movement. She states, “I’ve had enough. I can’t do this anymore. I want to go home right now.” The nurse knows that these signs indicate the client is in the: Second stage of labor Fourth stage of labor Transition phase of labor. Active phase of labor